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Substance Abuse Treatment, Prevention, and Policy
Published in: Substance Abuse Treatment, Prevention, and Policy 1/2021

Open Access 01-12-2021 | Buprenorphine | Research

Changes in opioid-related deaths following increased access to opioid substitution treatment

Authors: Lisa Andersson, Anders Håkansson, Jonas Berge, Björn Johnson

Published in: Substance Abuse Treatment, Prevention, and Policy | Issue 1/2021

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Abstract

Background

Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths.

Methods

Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention.

Results

There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89–1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12–6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51–1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84–0,97, p= 0.004).

Conclusions

Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.
Appendix
Available only for authorised users
Footnotes
1
Medication costs in Sweden are restricted to a maximum of SEK 2300 (≈ € 230) per patient and year.
 
2
The proportion of deaths among patients involuntarily discharged from OST cannot be examined as we lack information on the total number of individuals who were involuntarily discharged prior to and after the patient choice reform.
 
3
There were only 15 individuals < 65 years of age in the larger material that included all opioid deaths in Skåne who died as a result of intoxication with heroin, methadone, buprenorphine, fentanyl, morphine or oxycodone, who were excluded from the study due to lack of a history of illicit drug use. In nine of these cases the manner of death was suicide. Only five individuals were below 40 years of age.
 
4
Data for 2018 and 2019 have been excluded from the comparison, mainly because of two important national policy changes that occurred in early 2018: (1) Naloxone programs were introduced in several regions, including Stockholm and Skåne, which may have affected drug mortality. (2) Two internet-based sellers of fentanyl analogues were prosecuted for involuntary manslaughter in February 2018, which led to the effect that the online supply of these substances practically ceased overnight. The number of deaths related to fentanyl analogues decreased by 90% between 2017 and 2018, from 101 cases in 2017 to 11 cases in 2018.
 
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Metadata
Title
Changes in opioid-related deaths following increased access to opioid substitution treatment
Authors
Lisa Andersson
Anders Håkansson
Jonas Berge
Björn Johnson
Publication date
01-12-2021
Publisher
BioMed Central
Published in
Substance Abuse Treatment, Prevention, and Policy / Issue 1/2021
Electronic ISSN: 1747-597X
DOI
https://doi.org/10.1186/s13011-021-00351-4

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